Failure to Document and Administer Wound Care and Refusals Resulting in Infection
Penalty
Summary
The facility failed to provide the highest quality of care and ensure that a resident with skin concerns received treatment and care in accordance with professional standards of practice. The resident, who was cognitively intact and required substantial to maximum assistance for mobility, had a history of high blood pressure, obesity, and chronic pain. Over the course of several weeks, the resident developed multiple open areas and wounds under the abdominal folds and pannus, which were documented in skin assessments and required specific wound care treatments per physician orders. Despite clear orders for wound care, the facility did not consistently document the administration of treatments or the resident's refusals. The Treatment Administration Record and Medication Administration Record showed multiple instances where wound care was not administered, with some entries noting resident refusal and others lacking any supporting documentation or explanation. Additionally, there were gaps in weekly skin assessments, and measurements were sometimes omitted. The resident reported that treatments were often missed or delayed, particularly when they were in bed, and staff did not return to provide care when requested. Interviews with facility staff, including the ADON, LPNs, DON, and the MDS/Care Plan coordinator, confirmed that refusals and wound care should be documented and care planned, and that weekly skin assessments were expected. However, staff were not always aware of missed assessments or incomplete documentation. The lack of consistent documentation and follow-through on wound care and refusals ultimately led to the resident developing cellulitis, requiring antibiotic treatment and further physician intervention.